PERMISSION TO REPRINT PUBLISHED MATERIAL Date: __________________________ _____________________ (the “Owner”) has received the request of ____________________ (the “Requestor”), in a letter dated _____________________, _____, to reproduce the Material (as defined below). The Owner hereby grants the request on the following terms and conditions, which terms and conditions Requestor hereby accepts: (1) The published work (the “Original Work”) that is the subject of this agreement (the “Agreement”) is the following: Author: Title: Name of Publication: Date of Original Publication: The Owner is the sole copyright holder of the Original Work. (2) Permission is hereby granted to use the following selection from the Original Work: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (the “Material”). The Material represents approximately _________ % of the Original Work. [A copy of the Material is attached to this Agreement.] (3) The Material may be used only as follows, without deletions from, additions to, or changes in the text thereof: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _______________________________________________________________. (4) The Material [will not be used in a seminar or other educational activity] [will be used in a seminar or other educational activity as follows: __________________________________________________________________ __________________________________________________________________ _______________________________________________________________.] (5) In consideration for the grant of the Owner’s permission to use the Material, the Requestor agrees to pay a one time fee of $__________________ (the “Fee”). The permissions granted under thi